2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
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Appendix F. Prior Authorization GuideAppendix F. Prior Authorization GuideAppendix F. PriorAuthorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions <strong>and</strong> Limitations*Member must be < 21 years of ageaccredited residentialtreatment center servicesadaptive skills building(autism)adult day health(ABCB service**)adult psychologicalrehabilitation servicesYesYesYesYesNONCOVERED SERVICES: Services furnished in residential treatment centers aresubject to the limitations <strong>and</strong> coverage restrictions which exist for other Medicaidservices. See 8.301.3 NMAC, General Noncovered Services. Medicaid does not coverthe following specific services for recipients in residential treatment centers:• A. Services not considered medically necessary for the condition of the recipient, asdetermined by PHP• B. Services for which prior approval was not requested• C. Services furnished to ineligible individuals; residential treatment center servicesare covered only for recipients under 21 years of age• D. Services furnished after Medical Assistance Division (MAD) or its designeedetermines that the recipient no longer needs Joint Commission on Accreditation of<strong>Healthcare</strong> Organizations (JCAHO) accredited residential treatment center care• E. Formal educational <strong>and</strong> services which relate to traditional academic subjects orvocational training• F. Experimental or investigational procedures, technologies, or non-drug therapies<strong>and</strong> related services• G. Drugs classified as “ineffective” by the FDA drug evaluation• H. Activity therapy, group activities, <strong>and</strong> other services primarily recreational ordiversional in natureMember must be < 19, unless in high school, in which case benefits can be continued upto age 22. Services received under the federal Individuals with Disabilities EducationImprovement Act of 2004 <strong>and</strong> related state laws that place responsibility on state <strong>and</strong>local school boards for providing specialized education <strong>and</strong> related services to children 3to 22 years of age who have autism spectrum disorder are not covered under this plan.Only for those who qualify for Nursing Facility Level of Care <strong>and</strong> select Agency BasedCommunity Benefits (ABCB). Services must be at least 2 hours per day for one or moredays per week.• A. Adult day health services can be provided only by eligible adult day healthagencies.• B. Adult day health facilities must be licensed by Department of Health (DOH) as anadult day care facility.• C. Adult day health facilities must meet all requirements <strong>and</strong> regulations set forth byDOH as an adult day care facility.• D. An adult day health care provider agency must comply with the provisions ofTitle II <strong>and</strong> III of the Americans with Disabilities Act of 1990 (42 U.S.C. Section12101 et seq.).• E. An adult day health care provider agency must comply with all applicable city,county, or state regulations governing transportation services. This service is notprovided to ABCB recipients in Assisted Living facilities.Pending final determination of behavioral health UM criteria.F-12014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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